Delta wave automatic mapping and catheter ablation without fluoroscopy in patients with overt accessory pathway: a new workflow

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Catheter ablation of accessory pathways (AP) located in the posterior pyramidal space are often challenging due to its anatomical complexity. Scarce of data are available about the ECG features that might indicate when an epicardial approach is required in the ablation of the posteroseptal AP. Objective The purpose of this retrospective study was to describe the electrocardiographic features of posteroseptal AP which have been successfully ablated with epicardial approach and identify electrocardiographic predictors for epicardial AP location. Methods The 12 leads ECG of 75 patients with posteroseptal accessory pathways who were successfully ablated were retrospectively analyzed. ECG features for epicardial location described already in published studies have been considered (negative delta wave in DII, positive delta wave in aVR, high amplitude S wave in V6). Additionally the characteristics of the initial 40 ms of the delta wave in lead V1 (measured from the earliest QRS deflection in 12 leads) during full pre-excitation have been investigated. Results Of 75 patients with posteroseptal AP that undergone catheter ablation, 40 (53.3%) had successful epicardial ablation. An initial isoelectric or biphasic delta wave in lead V1 proved the highest sensitivity (82.5 %) respectively positive predictive value (97 %) and specificity (97 %) for an epicardial location of the AP. Deep S wave in V6 proved lower sensitivity (37.5%) and positive predictive value (68%) but higher specificity (80%) for epicardial location of AP. The specificity and sensitivity for epicardial location of AP of negative delta wave in DII were lower, however it failed to reach statistical significance. Conclusion This study shows that an initially isoelectric or biphasic delta wave aspect in lead V1 has a higher specificity, sensitivity and positive predictive value than previously described ECG markers for epicardial location of posteroseptal accessory pathways.

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Identifying the Location of an Accessory Pathway in Pre-Excitation Syndromes Using an Artificial Intelligence-Based Algorithm

Journal of Clinical Medicine ◽

10.3390/jcm10194394 ◽

2021 ◽

Vol 10 (19) ◽

pp. 4394

Author(s):

Thomas Senoner ◽

Bernhard Pfeifer ◽

Fabian Barbieri ◽

Agne Adukauskaite ◽

Wolfgang Dichtl ◽

...

Keyword(s):

Artificial Intelligence ◽

Catheter Ablation ◽

Predictive Accuracy ◽

Accessory Pathway ◽

Electrophysiologic Study ◽

Delta Wave ◽

Wpw Syndrome ◽

Invasive Electrophysiologic ◽

Anatomic Localization ◽

Excellent Accuracy

(1) Background: The exact anatomic localization of the accessory pathway (AP) in patients with Wolff–Parkinson–White (WPW) syndrome still relies on an invasive electrophysiologic study, which has its own inherent risks. Determining the AP localization using a 12-lead ECG circumvents this risk but is of limited diagnostic accuracy. We developed and validated an artificial intelligence-based algorithm (location of accessory pathway artificial intelligence (locAP AI)) using a neural network to identify the AP location in WPW syndrome patients based on the delta-wave polarity in the 12-lead ECG. (2) Methods: The study included 357 consecutive WPW syndrome patients who underwent successful catheter ablation at our institution. Delta-wave polarity was assessed by four independent electrophysiologists, unaware of the site of successful catheter ablation. LocAP AI was trained and internally validated in 357 patients to identify the correct AP location among 14 possible locations. The AP location was also determined using three established tree-based, ECG-based algorithms (Arruda, Milstein, and Fitzpatrick), which provide limited resolutions of 10, 5, and 8 AP locations, respectively. (3) Results: LocAP AI identified the correct AP location with an accuracy of 85.7% (95% CI 79.6–90.5, p < 0.0001). The algorithms by Arruda, Milstein, and Fitzpatrick yielded a predictive accuracy of 53.2%, 65.6%, and 44.7%, respectively. At comparable resolutions, the locAP AI achieved a predictive accuracy of 95.0%, 94.9%, and 95.6%, respectively (p < 0.001 for differences). (4) Conclusions: Our AI-based algorithm provided excellent accuracy in predicting the correct AP location. Remarkably, this accuracy is achieved at an even higher resolution of possible anatomical locations compared to established tree-based algorithms.

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Methodology of Typical Accessory Pathway Catheter Ablation

Cardiac Electrophysiology Clinics ◽

10.1016/j.ccep.2020.09.003 ◽

2020 ◽

Vol 12 (4) ◽

pp. 541-553

Author(s):

Jorge Romero ◽

Juan Carlos Diaz ◽

Isabella Alviz ◽

Juan Bello ◽

Sutopa Purkayastha ◽

...

Keyword(s):

Catheter Ablation ◽

Accessory Pathway

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Successful catheter ablation by radiofrequency energy of posteroseptal accessory pathway in a patient with drug refractory Wolff--Parkinson--White syndrome

European Heart Journal ◽

10.1093/eurheartj/12.12.1321 ◽

1991 ◽

Vol 12 (12) ◽

pp. 1321-1325

Author(s):

P. DELISE ◽

A. BONSO ◽

A. RAVIELE ◽

R. CAZZIN ◽

F. DI PEDE ◽

...

Keyword(s):

Catheter Ablation ◽

Accessory Pathway ◽

Radiofrequency Energy ◽

White Syndrome ◽

Posteroseptal Accessory Pathway ◽

Wolff Parkinson White Syndrome

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Catheter Ablation of an Accessory Pathway within the Marshall Vein in a Patient with Mechanical Mitral Valve

Pacing and Clinical Electrophysiology ◽

10.1111/j.1540-8159.2011.03089.x ◽

2011 ◽

Vol 36 (5) ◽

pp. e132-e135 ◽

Cited By ~ 3

Author(s):

AMIR ASLANI ◽

MEHDI MORADI ◽

JALAL KHEIRKHAH ◽

MAJID HAGHJOO

Keyword(s):

Catheter Ablation ◽

Mitral Valve ◽

Accessory Pathway

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Catheter ablation for atrial fibrillation in very young patients

EP Europace ◽

10.1093/europace/euab116.202 ◽

2021 ◽

Vol 23 (Supplement_3) ◽

Author(s):

K Yalin ◽

B Ikitimur ◽

T Aksu ◽

AU Soysal ◽

E Lyan ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Pulmonary Vein ◽

Accessory Pathway ◽

Young Patients ◽

Old Patients ◽

Index Procedure ◽

Holter Ecg ◽

History Of

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Pulmonary vein automaticity is an established trigger of paroxysmal atrial fibrillation (PAF) making pulmonary vein isolation (PVI) the cornerstone for catheter ablation. However, data on triggers of AF and catheter ablation strategy in very young (<30 years old) patients are sparse. Methods and results: Sixteen young patients (mean age 25.2 ± 4.9 years; 75% men) with recurrent drug refractory PAF underwent EP study and ablation at 3 EP centers. None of the patients had structural heart disease or family history of AF. EP study revealed degeneration of induced supraventricular tachycardia (SVT) into AF in 5 patients (n = 5, 31.2%). Induced SVTs were left lateral concealed accessory pathway mediated orthodromic AVRT in two patients, typical AVNRT in two patients, and left superior PV tachycardia in one patient respectively. In patients with induced SVTs, SVT ablation without PVI was performed as an index procedure. Remaining patients underwent second generation cryoballoon (CB-2) based PVI (n = 11, 68.7%). There were no major complications related to ablation procedures. Follow-up was based on outpatient visits including 24-h Holter-ECG at 3, 6 and, 12 months post ablation, or additional Holter-ECG was ordered in case of symptoms suggesting recurrence. Recurrence was defined as any atrial tachyarrhythmia (ATA) episode >30s following a 3-month blanking period. After a median follow-up of 18.3 ± 6.2 months, 13 of 16 (81.2%) patients were free of ATA recurrence. None of the patients belonging to SVT ablation only group experienced ATA recurrence. Three patients with previous CB-2 PVI recurred, one had typical atrial flutter and underwent CTI ablation, remaining 2 patients had AF recurrence and medically followed. Conclusion In a considerable fraction of young adult patients with history of PAF SVTs may be responsible and SVT ablation without PVI may be sufficient as an index procedure. Catheter ablation AF seems to be safe and effective in this population.

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Split Accessory Pathway Potentials in a Patient with Antidromic AVRT

10.22541/au.163750790.04448113/v1 ◽

2021 ◽

Author(s):

Weizhuo Liu ◽

Wentao Gu ◽

Xinping Luo ◽

Jian Li ◽

Nanqing Xiong

Keyword(s):

Accessory Pathway ◽

Conduction Delay ◽

Tricuspid Annulus ◽

Reentrant Tachycardia ◽

Delta Wave ◽

Electrophysiology Study ◽

Isoproterenol Infusion

A 27-year-old female presenting palpitation without ECG documentation underwent electrophysiology study. EP study revealed atrioventricular accessory pathway with poor and unidirectional pathway conduction, and a fasciculoventricular pathway. During isoproterenol infusion, delta wave promptly became prominent, after which an antidromic AV reentrant tachycardia was induced. When the pathway was mapped, widely split double pathway potentials were observed at 12 o’clock site of tricuspid annulus during mild preexcitation, demonstrating an example of intra-pathway conduction delay, which can be reversed by isoproterenol. Ablation at the site caused accelerated pathway rhythm and eliminated the pathway, rendering the tachycardia non-inducible.

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Successful Radiofrequency Catheter Ablation of Incessant Ventricular Tachycardia with a Delta Wave-like Beginning of the QRS Complex.

Japanese Heart Journal ◽

10.1536/jhj.40.671 ◽

1999 ◽

Vol 40 (5) ◽

pp. 671-675 ◽

Cited By ~ 3

Author(s):

Hidehiko NAGASAWA ◽

Akira FUJIKI ◽

Masahiro USUI ◽

Koichi MIZUMAKI ◽

Hideki HAYASHI ◽

...

Keyword(s):

Ventricular Tachycardia ◽

Catheter Ablation ◽

Radiofrequency Catheter Ablation ◽

Qrs Complex ◽

Delta Wave

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The role of the accessory pathway radiofrequency catheter ablation in the secondary prevention of the malignant tachyarrhythmias in patients with Wolff-Parkinson-White syndrome

Vojnosanitetski pregled ◽

10.2298/vsp1001048m ◽

2010 ◽

Vol 67 (1) ◽

pp. 48-54 ◽

Cited By ~ 3

Author(s):

Nebojsa Mujovic ◽

Miodrag Grujic ◽

Stevan Mrdja ◽

Aleksandar Kocijancic ◽

Tatjana Potpara ◽

...

Keyword(s):

Physical Activity ◽

Atrial Fibrillation ◽

Catheter Ablation ◽

Secondary Prevention ◽

Emotional Stress ◽

Drug Administration ◽

Clinical Manifestation ◽

Accessory Pathway

Background/Aim. The occurrence of atrial fibrillation (AF) in the presence of an accessory pathway (AP) that conducts rapidly is potentially lethal because the rapid ventricular response may lead to ventricular fibrillation (VF). The aim of the study was to determine long-term efficacy of AP catheter-ablation using radiofrequency (RF) current in secondary prevention of VF in WPW patients. Methods. Study included a total of 192 symptomatic WPW patients who underwent RF catheter-ablation of AP in our institution from 1994 to 2007 and were available for clinical follow-up for more than 3 months after procedure. Results. Before ablation, VF was recorded in total of 27 patients (14.1%). In 14 of patients (51.9%) VF was the first clinical manifestation of WPW syndrome. A total of 35 VF episodes were identified in 27 patients. The occurrence of VF was preceded by physical activity or emotional stress in 17.1% of cases, by alcohol abuse in 2.9% and by inappropriate intravenous drug administration in 28.6%. In addition, no clear precipitating factor was identified in 40% of VF cases, while informations about activities preceding 11.4% of VF episodes were not available. The follow-up of 5.7 ? 3.3 years was obtained in all of 27 VF patients. Of the 20 patients who underwent successful AP ablation, all were alive, without syncope or ventricular tachyarrhythmias during long-term follow-up. In 4 of 7 unsuccessfully treated patients, recurrence of supraventricular tachycardia and/or preexcited atrial fibrillation were recorded; one of these patients suddenly died of VF, 6 years after procedure. Conclusion. In significant proportion of WPW patients, VF was the first clinical manifestation of WPW syndrome, often precipitated by physical activity, emotional stress or inappropriate drug administration. Successful elimination of AP by percutaneous RF catheter-ablation is highly effective in secondary prevention of life-threatening tachyarrhythmias in patients with ventricular preexcitation.

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